Healthcare Provider Details

I. General information

NPI: 1669007365
Provider Name (Legal Business Name): BETZANAHY LEYVA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W WATKINS RD
PHOENIX AZ
85003-2830
US

IV. Provider business mailing address

2055 E NANCY LN
PHOENIX AZ
85042-4662
US

V. Phone/Fax

Practice location:
  • Phone: 602-254-3338
  • Fax:
Mailing address:
  • Phone: 602-908-5827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD011014
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: